MEDICARE: MRS. BRENDA GALVIN BOOTH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	5000596	NC
2	363LA2200X	Adult Health Nurse Practitioner	2005003026	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2005003026	OTHER	MD	AMERICAN NURSES CREDENTIALING CENTER

General Provider Information

NPI Number	:	1255417838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA GALVIN BOOTH NP

Provider Business Mailing Address
First Line	:	112 PARKVIEW AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-4908
Country	:	US
Telephone Number	:	910-323-0334
Fax Number	:	888-391-5874

Provider Business Practice Location Address
First Line	:	1248 FORT BRAGG RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-4981
Country	:	US
Telephone Number	:	910-323-0334
Fax Number	:	888-391-5874

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	06/19/2012

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